CANCERPresented By:Supta Sarkar

HHM-2013-10Dept. of Foods & Nutrition

SEE INSIDE…

• Introduction: Cancer• Some cancers related to the digestive system• The side effects of cancer treatment and the

nutrition therapy• General systemic reactions in cancer • Cancer and nutrients• Nutritional care in cancer• Conclusion

CANCER‘WHEN GOOD CELLS GO BAD’

Cancer refers to uncontrolled cell growth.

Cancer can also refers to malignant neoplasm or tumours.

Tumours can be benign or malignant.

Malignant tumor have the potentiality of metastasis.

Mutation causes cancer: Inherited or

acquired.

CANCER SCENARIO WORLDWIDE:

WHO, 2012 REPORT:

• Cancer is the second most common disease worldwide.

• 8.2 million people worldwide died from cancer in 2012. (WHO, 2012).

• About 30% of cancer deaths are due to the five leading behavioral and dietary risks: high body mass index, low fruit and vegetable intake, lack of physical activity, tobacco use, alcohol use.

• 30% of cancers could be prevented (WHO, 2012)

INDIA• According to 1991 Indian census data, about

6,09,000 cancer cases had been observed.

• But the number of cancer cases in India has drastically increased in the last decade to reach 8,06, 000.

• Cases registered by 2010: 9,79,786.

• Total cases in 2012: 10,15,000 population (WHO, 2012).

HOW GOOD CELLS GO BAD?

Carcinogenesis • Different types of cells have different life

spans, depending on their location and function.

• New cells are produced by the process of cell division, mitosis.

• 2 types of genes that causes cell growth and division: Proto-oncogenes & Tumor suppressor genes.

• Proto-oncogenes: Genes which promote cell growth and reproduction.

• Tumor suppressor genes: Genes which inhibit cell division, repair DNA function and tell cells when to die(Apopstosis).

• In order for a normal cell to transform into a cancer cell, these genes must be altered.

• Typically, changes in many genes are required to transform a normal cell into a cancer cell.

• According to research findings from the Cancer Genome Project, most cancer cells possess 60 or more mutations.

When a proto-oncogene mutates or there are too many copies of it, it becomes a "bad" gene.

Fig.: Seven proteins that regulate cell growth

Classification of cancer

Type Origin Example

Carcinoma Endoderm or ectoderm

Epithelial lining of gut (e.g.,

adenocarcinoma of colon) or

bronchus (e.g., squamous) cell or

small cell carcinoma of

bronchus

Sarcoma Mesoderm Osteosarcoma, Fibrosarcoma

Leukaemia White blood cell

Acute lymphoblastic

leukaemia

Lymphoma Monocyte, macrophag

e

Hodgkin’s disease

SOME CANCERS RELATED TO THE HUMAN DIGESTIVE SYSTEM

The Digestive System

Consists of mouth, pharynx(throat),

esophagus, stomach,

intestines, rectum and anus.

• The digestive tract breaks down food, absorbs nutrients and eliminates feces.

• The entire alimentary canal is lined with epithelial cells.

• When the replacement of these fast-growing cells is halted as a result of chemotherapy or radiation , painful side effects such as moth sores, sore throat and stomach upset can result.

• Damage to epithelium of the small intestine causes more than just discomfort.

• It can result in electrolyte loss through diarrhoea or malnutrition from malabsorption.

• The main function of the epithelium of the small intestine is to absorb nutrients with the help of villi and microvilli which produce the digestive enzymes.

• When cancer treatments injure the cells of the villi, some nutrients can no longer be digested or absorbed. This can result into malnutrition.

• Since the digestive system is open to the environment and its toxins it is a common site for cancer development.

“Every time you eat or drink, you are either feeding disease or fighting it”

Oropharyngeal Cancer Oropharynx is a middle part of the throat which includes the base of the tongue, the tonsils, the soft palate, and the walls of the pharynx.

Oropharyngeal cancers can be divided into two types:

1. HPV-positive cancers, which are related to Human Papilloma Virus infection 2. HPV-negative cancers, which are usually linked to alcohol or tobacco use.

Risk factors

• Smoking and chewing tobacco

• Heavy alcohol use• Chewing betel quid• Mucosal infection HPV• P53 mutation• Asbestos exposure • A diet low in fruits and

vegetables• Pickled or salted foods• Poor nutrition

A very high rates of nasopharyngeal carcinoma have been linked to the consumption

of salted fish (International Agency for Research on Cancer;

1993)

Sanchez et al., (2003) reported the beneficial effect of high

intake of vegetables and fruits on the risk of developing cancers

of the oral cavity and oropharynx in Spain, particularly

among current smokers and heavy alcohol drinkers.

Symptoms• Ulcers that do not heal• Persistent discomfort or pain in the mouth• White or red patches in the mouth or throat• Difficulty in swallowing• Speech problems• A lump in the neck• Weight loss• Bad breath (halitosis)• A lump or thickening on the lip• A lump in the mouth or throat• Unusual bleeding or numbness in the mouth• Loose teeth for no apparent reason• Difficulty moving the jaw

Treatment There are three main treatment options : Surgery, radiation therapy and chemotherapy. Surgery: • Primary tumor surgery, • Glossectomy (partial or total removal of the tongue),

• Mandibulectomy (partial or total removal of the jaw bone),

• Maxillectomy (partial or total removal of the hard palate i.e the bony roof of the mouth),

• Neck dissection (to remove some or all of the lymph nodes),

• Laryngectomy (partial or total removal of the larynx or voice box which is critical to swallowing),

• Tracheostomy (a hole in the neck when cancer is blocking the throat)

DIET THERAPY:

• If the swallowing problem is temporary, a nasogastric (NG) tube (inserted through the nose, down the esophagus, and into the stomach).

• If cancer is inhibiting the ability to swallow, a feeding device called a gastrostomy tube is placed through the skin and muscle of the abdomen directly into the stomach.

• Tubes placed into the stomach may also be temporary methods for maintaining nutrition until the person can safely and adequately swallow by mouth.

***

EsophagEAL Cancer

• It is the cancer arising from the esophagus—the foodpipe that runs between the throat and the stomach.

• Symptoms often include trouble swallowing and weight loss. Other symptoms may include pain with swallowing, a hoarse voice, enlarged lymph nodes (glands) around the clavicle (collarbone), a dry cough, and possibly coughing up or vomiting blood.

• The two main sub-types: squamous-cell carcinoma, and adenocarcinoma.

• Squamous-cell carcinoma arises from the skin cells that line the esophagus.

•  Adenocarcinoma arises from glandular cells present in the lower third of the esophagus.

• The most common causes of the squamous-cell type are: tobacco, alcohol, very hot drinks, rich and spicy foods and a poor diet.

• The most common causes of the adenocarcinoma type are smoking tobacco, obesity, and acid reflux.

• Pickled vegetable foods have shown to elevate the risks for oesophageal and gastric cancer (International Agency for Research on Cancer; 1993)

Treatment:Surgery: Esophagectomy

1. Transhiatal EsophagectomyIn this method, the surgeon makes incisions in the

neck and abdomen.

Most of the esophagus is removed through these incisions.

Typically the surgeon attaches the stomach to the remaining esophagus in the neck. Sometimes, a segment of the colon is used to connect the esophagus to the stomach.

2. Ivor-Lewis Esophagectomy

In this method, the surgeon makes one incision in the abdomen and one in the chest along the ribs.

The lower half of the esophagus is removed through the abdominal incision, and the stomach is attached to the upper esophagus in the chest.

3. Total Esophagectomy

In this method the entire esophagus is removed when there are large tumors in the middle of the esophagus. 

Post surgery nutritional problem:

Dumping syndromeDiarrhoea

Indigestion & colicFeeling or being sick

***

Stomach Cancer

• Stomach cancer or gastric cancer, is when cancer develops from the lining of the stomach.

• The most common cause is infection by the bacteria Helicobacter pylori.

• Other common causes include eating smoked foods, salt and salt-rich foods, red meat, processed meat, pickled vegetables, and smoking. 

• A fondness for salty tastes, especially salted foods such as pickled vegetable and dried & salted fishes has a significantly positive association with stomach cancer (Tajima,K & Tominaga,S. 1985)

Symptoms

In the early stages of stomach cancer:• Indigestion and

stomach discomfort• A bloated feeling

after eating• Mild nausea• Loss of appetite• Heartburn• Upper abdominal

pain

In more advanced stages of stomach cancer:• Discomfort in the upper or

middle part of the abdomen.• Blood in the stool (which

appears as black, tarry stools).• Vomiting or vomiting blood.• Weight loss.• Pain or bloating in the

stomach after eating.• Weakness or fatigue

associated with mild anemia (a deficiency in red blood cells).

TREATMENT

Surgery, chemotherapy, radiation, biological therapy.

SURGERY:1. Endoscopic mucosal resection

 (EMR): Treatment for early gastric cancer

(tumor only involves the mucosa)  In this procedure, the tumor,

together with the inner lining of stomach (mucosa), is removed from the wall of the stomach.

The advantage is that it is a much smaller operation than removing the stomach

If cancer is at the lower end of the stomach that connects with the duodenum only part of your stomach removed. This is called a partial gastrectomy.

The position of the tumour in

the stomach will affect how much of the stomach is removed.

After the operation the patient have a much smaller stomach but the valve (cardiac sphincter) between the oesophagus and stomach will still be there.

2. Partial gastrectomy

If the cancer is in the middle of the stomach the whole stomach need to be removed. This operation is called a total gastrectomy.

  After the operation the

oesophagus is joined directly to the small bowel. 

3.Total gastrectomy.

4. Gastric bypass (gastrojejunostomy):

• Tumors in the lower part of the stomach may grow large enough to block food from leaving the stomach.

• Thus bypass the lower part of the stomach is done.

• This is done by linking part of the small intestine (called the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.

FIG.: GASTRIC BYPASS

Post surgery nutritional problem• Dumping syndrome• Feeling full after eating and drinking • Weight loss and malnutrition• Poor appetite• Indigestion and/or reflux (this can be continuous)• Diarrhoea• Bilious vomiting.• Calcium malabsorption• Anaemia caused by iron and vitamin B12 deficiency• Narrowing of the join between the gullet and the small

bowel after surgery (anastomosis), which can make it difficult to swallow food.

DIET THERAPY

If only part of the stomach is removed very small frequent meals should be given at first.

As the stomach will gradually stretch larger amount can be given at a time.

Patient may need to be given vitamin B12 supplementation for the rest of the life to prevent anaemia and nerve problems.

For a while before or after stomach surgery the patient may need to have only liquid food.

NUTRITION THERAPY

Enteral Nutrition: 

• Some people with stomach cancer are not able to eat or drink enough to get enough nutrition.

• A minor operation can be done to place a feeding tube through the skin of the abdomen and into the distal part of the stomach (known as a G tube) or into the small intestine (known as a J tube). Liquid nutrition can then be put directly into the tube.

PARENTERAL NUTRITION: For some patients, the most appropriate option for receiving

nutrition may be through an IV (i.e., parenteral nutrition).

To receive this alternative form of nutrition therapy, a thin plastic tube called a catheter is first inserted into a large vein in the arm or chest.

The catheter can remain for as long as one need to receive parenteral nutrition.

For stomach cancer patients, the catheter allows to receive a liquid mixture of vitamins, minerals, protein, carbohydrates and fats.

Each patient's optimal mixture may differ according to the body’s nutritional status.

Small intestine Cancer

It is relatively rare compared to other gastrointestinal malignancies such as gastric cancer (stomach cancer) and colorectal cancer.

Small intestine cancer can be subdivided into duodenal cancer (the first part of the small intestine) and cancer of the jejunum and ileum (the later two parts of the small intestine).

Duodenal cancer has more in common with stomach cancer, while cancer of the jejunum and ileum have more in common with colorectal cancer.

RISK FACTORS FOR SMALL INTESTINE CANCER INCLUDE:

• Crohn's disease

• Celiac disease

• Radiation exposure

• Hereditary gastrointestinal cancer

• Males are 25% more likely to develop the disease

TREATMENT

SURGERY is often the only treatment.

Resection: Usually this surgery is done through a cut made in the

abdomen.

This operation removes the piece of intestine that has the tumor and some of the normal tissue on either side of the tumor.

After surgery, it can take a few days before the patient can eat and drink normally.

Removing a small piece of intestine usually doesn’t cause long-term problems with eating or bowel movements.

PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

This operation is used to treat cancers of the duodenum, although it is more often used to treat pancreatic cancer.

It removes the duodenum, part of the pancreas, nearby lymph nodes and part of the stomach.

The gallbladder and part of the common bile duct are removed and the remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine.

Palliative surgery• If the cancer cannot be completely removed because it has spread too

far in the abdomen, the surgeon may do an operation to help improve some of the symptoms that the cancer is causing. This is known as palliative surgery.

• Often, these operations are done to relieve a blocked intestine, to decrease pain, nausea, and vomiting, and allow the patient to eat normally for some time.

• If possible, the surgeon will remove enough of the tumor and nearby intestine to allow digested food to pass through.

• In very advanced situations, a fairly rigid tube (called a stent) is passed through the blocked area and left in place so digested food can pass.

• If this can’t be done, a tube may be placed in the stomach to drain it and decrease problems with nausea and vomiting.

Colorectal Cancer

Malignancy of the colon, rectum and anus.The colon is the most common site for

tumors in gastrointestinal tract.It is one of the leading cancer worldwide.

Risk Factors for COLON CANCER:

• Diet, obesity, smoking, and not enough physical activity.

• Dietary factors that increase the risk include red and processed meat, as well as alcohol.

• Low folate and high alcohol intake is associated with changes in promoter hypermethylation of DNA in CRC (Engeland,M.V., 2003).

• Another risk factor is inflammatory bowel disease, which includes  Crohn's disease and ulcerative colitis.

• Some of the inherited conditions that can cause colorectal cancer include: familial adenomatous polyposis and hereditary non-polyposis colon cancer.

TREATMENT:

If the left side of the colon is removed, the operation is called a left hemi

colectomy.

If the middle part of the bowel is removed (the transverse colon) it is called a transverse colectomy.

If the right side of the colon is removed, it is called a right hemi

colectomy.

If the sigmoid colon is removed it is called a sigmoid colectomy.

POST SURGERY NUTRITIONAL PROBLEM:

• Diarrhoea• Constipation

• Feeling bloated or passing a lot of wind• Having a sore bottom.

The side effects of cancer treatment and the nutrition

therapy

Nausea and vomiting

• Vomiting is stimulated by sensory receptors in the stomach including stretch receptors and chemoreceptors.

• The emetic center in the brain responds to these signals by causing a wave of reverse peristalsis.

• Chemotherapy causes nausea by acting both on the brain and stomach.

MNT• Avoid eating 2hrs before or after a treatment.• Eat small, frequent meals.• Do not drink large amount of liquid with your meal. Too much

food or liquid can expand the stomach activating the stretch receptors & stimulating the emetic center.

• Do not lie down immediately after meal.• Avoid greasy or high fat foods. As it remain in the stomach

longer increasing the chance to vomit.• Avoid foods with strong odors or flavors as it causes ‘nausea

flashback’.• Eat food that are easy to digest. • Avoid raw or high fibrous foods.

• It is recommended to use ginger as a complementary therapy in the management of Chemotherapy Induced Nausea and Vomiting. (Muthia et al, 2013)

Dry mouth & difficult swallowing

• It causes difficulty chewing.

• Some chemotherapy drugs contain bleomycin & dactinomycin that cause a temporary dryness of the mouth.

• Radiation may damage the salivary glands.

• Surgery that removes salivary gland will reduce secretion.

MNT• Tart taste will stimulate salivary flow. Lemon juice

about 15mins before mealtime.

• Small sips of water. This makes food easier to swallow.

• Add pickle, extra sauce or gravies.

• Suck on ice cubes.

• Dry mouth can be a breeding ground for bacteria so maintain good oral health.

Taste alteration

• Stimulation of the taste bud result in taste sensation.

• Since the taste buds are formed from the taste-dividing epithelial tissue which are particularly sensitive to cancer therapies.

MNT• Avoid eating favorite foods before chemotherapy.

The changes in taste may cause an unpleasant association with the food.

• Depending on tolerance use the amount of salt and sugar.

• Use herb spices to increase the flavor.

• Foods that are cold at room temp may be more palatable than hotter one.

• Zinc supplement may increase taste sensitivity.

Anorexia

Toxic effects of therapy: Side effects of treatment such as nausea, sore mouth, stomach cramps. And taste changes can all decrease the desire to eat.

Localized effects of the tumor: Tumors in the gastrointestinal tract that cause blockages can decrease appetite. Some tumors produce chemicals that affect the endocrine system, resulting in early satiety.

Early satiety may kill the appetite, making proper nutrition difficult to achieve.

Surgery: Surgical removal of any part of the gastrointestinal tract can decrease the ability & desire to eat.

MNT• Appetite is usually best first thing in the morning, so plan the largest meal of

the day at breakfast.

• Six small meals a day instead of three large meals.

• Provide to whenever hungry. Do not wait for meal time.

• Keep cooking odours to a minimum.

• Give the most nutrient dense food first.

• Avoid drinking liquid with the meal.

• Liquid meals are more appealing than solids like smoothies.

• Avoid raw vegetables.

• High calorie, high protein beverages.

• Light exercise may stimulate appetite.

Mucositis begins with the tissues feeling dry and looking red.

The mouth and throat are sore. This is followed by swelling, ulcerations and bleeding.

CAUSES OF MUCOSITIS: Chemotherapy: Treatment prevents the division of the

rapidly dividing mucous membrane cells of the tongue, cheek, lips, gums, and palate as well as the floor of the mouth and esophagus. When the top layers of the cells are shed, they are not replaced. This causes inflammation.

Radiotherapy may also damage the mucous membranes of the mouth and throat.

Oral and esophageal mucositis

MNT:• Give soft non-irritating foods such as nonfat yoghurt,

oatmeal, pureed vegetables and mashed potatoes & yams.

• Serve food lukewarm or cold.

• Avoid acidic, tart or spicy foods.

• Avoid dry rough foods as toast.

• If sores are confined to the tongue provide a straw to bypass them.

• Use more of Vit. C & E on diet.

Constipation• Treatment side effects: sore mouth, nausea,

vomiting and lack of appetite. These greatly reduce the consumption of fibrous foods causing constipation.

• Medication: For example the opioid painkillers can reduce peristalsis.

• Decreased activity: cancer treatment often leaves a patient feeling tired and drained.

• Stress

• Loss of nerve function in the colonic muscle: Radiation and surgery can sometimes result in a temporary or permanent loss of muscle tone due to nerve damage.

MNT• Increasing dietary fiber.

• Increasing amount of water.

• Nuts and seeds as they will give not only fiber but also healthy fats which will increase the calorie.

• Natural laxative foods as prune and prune juice, apple and pear juice.

• Drinking hot or warm liquid before a meal stimulates gastrointestinal tract movement.

DIARRHEA

Chemotherapy or radiation sometimes has a toxic effect on the lining of the small intestine.

Some drugs can injure the villi & microvilli preventing the absorption of some nutrients decreasing the amount of enzymes produced for digestion.

In large intestine some drugs increase the rate of peristalsis and the transit time through the colon, resulting in less time for the water to be reabsorbed.

Some temporary intolerance to milk sugar because of the temporary absence of lactase.

MNT

• Hot food stimulate muscle movement and may cause diarrhea. Try cold food at room temperature.

• Avoid raw foods.

• Avoid milk or other dairy products.

• Give food that are easily digestible or absorbed.

SOME GENERAL SYSTEMIC REACTIONS IN CANCER

ABNORMALITIES IN METABOLISM Cancer cells reprogram their metabolic pathways to meet their abnormal

demands for proliferation and survival (Tennant et al, 2010).

It has long been recognized that cancer cells need a higher rate of metabolism to support their accelerated proliferation rate (Cairns et al, 2011).

Cancer cells take up and utilize much more glucose for glycolysis compared to normal cells, even in the normoxic condition (Warberg, 1956).

Abnormalities in glucose metabolism. Cancer patients cannot produce glucose efficiently from carbohydrates. Gluconeogenesis increases. Straining the supply of body proteins. Many patients develop insulin resistance. Increased insulin resistance

There is increased lipolysis, free fatty acids and glycerol turnover and decreased lipogenesis and hyperlipidemia.

The rates of whole body catabolic rate exceeds that of synthetic rate.

Fat oxidation rates are higher.Depletion of body protein occurs. Albumin is depleted.Branched chain amino acid infusion can decrease

protein catabolism.These metabolic abnormalities may be the cause

for the failure to gain lean body mass or maintain healthy body weight inspite of receiving adequate energy and nutrients.

ANOREXIA

Often accompanied by depression or discomfort from normal eating.

Contributes to limited nutrient intake

Causes imbalance of decreased intake & increased demand.

Creates a negative nitrogen balance & thus wasting.

Can lead to cancer cachexia

Occurs in 80% of cancer patients.

A study by Cangiano,1996 suggests that: Brain tryptophan and serotonin

concentrations seem to play a pivotal role in the regulation of eating behavior.

Increased brain serotonin activity is indeed associated with a reduction of food intake.

Reducing brain tryptophan availability represents a possible mechanism to restore brain serotonin activity to normal.

There is evidence that the oral administration of neutral amino acids competing with tryptophan for brain entry results in a significant improvement of cancer anorexia.

WASTING

Progressive weight loss is a common feature of many types of cancer and is responsible not only for a poor quality of life and poor response to chemotherapy, but also a shorter survival time than is found in patients with comparable tumors without weight loss (Tisdale,1999).

The combined effects of a poor appetite, accelerated and abnormal metabolism and diversion of nutrients for tumor growth results in a lower supply of energy and nutrients at instances when demands are high.

Various factors have been investigated as mediators of tissue wasting in cachexia. These include cytokines such as tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interferon-γ (IFN-γ) and leukemia inhibitory factor (LIF), as well as tumor-derived factors such as lipid mobilizing factor (LMF) and protein mobilizing factor (PMF), which can directly mobilize fatty acids and amino acids from adipose tissue and skeletal muscle respectively (Tisdale,1999).

MALABSORPTION

• Can occur due to blind loop syndrome.

• Bacterial overgrowth may result in steatorrhoea & Vit.B12 deficiency.

• Malignancy involving pancreas or bile duct may limit the function of digestive enzymes or bile salts.

• Surgery involving partial or total organ of digestive system may lead to malabsorption.

• Chemotherapy or radiotherapy causing damage to the epithelial lining of the digestive system.

FLUID-ELECTROLYTE IMBALANCES

• Vomiting and diarrhoea not only bring loss of water and electrolyte but also water soluble vitamins

• Villous adenoma and adenocarcinomas of the colon can contribute to severe electrolyte imbalance.

ANAEMIA

• May be compounded by a number of factors: anorexia with less intake of nutrients necessary for haemoglobin synthesis, iron, protein, folic acid, vit.B12, and C.

• Malabsorption of the nutrients.

• Increased hemolysis

• Bleeding of ulcerated lesions

• Presence of fistulas.

HYPERCALCEMIA• It is one of the most common metabolic complication of cancer.

• Approximately 20-40% of patients with breast, squamous, bladder & renal carcinoma develop hypercalcemia at some point in their disease.

• The three main sites of regulation of calcium and phosphorus metabolism, as at present understood, are the intestine which is the portal of entry, the bones which are the storehouse and the kidneys which provide the excretory channel.

• Hypercalcemia, which is not uncommon in cancer patients, is usually associated with osteolytic secondaries in bone. In such cases it is usually due to erosion of bone by actively growing tumour cells and the mechanism is clear(Watson, 1963).

OSTEOMALACIA

• Certain tumours reduce plasma calcitriol concentration in conjuction with hypophosphatemia, thereby inducing an oncogenic osteomalacia.

• Gastrointestinal malabsorption of calcium and phosphate has been observed.

Cancer and nutrients

Carbohydrate & cancerOne of the purposes of nutrition therapy for cancer is to deny the

growing tumor glucose while providing enough to feed the brain and to form red blood cells.

This can be done in a crude way by keeping the blood sugar levels even.

One way is to eat foods that have low glycemic index.

Another way can be by low carb diet. A low carb diet is usually one that gets 40 percent of its calories from carbohydrate.

Positive caloric balance and the resulting accumulation of body fat during adult life also increase the risk of important human cancers. The best-established relationships are with cancers of the endometrium and gall bladder (Austin et al, 1991).

Cancer cell change the metabolism of protein so that more amino acids are available for tumor growth.

Causes a loss of muscle tissue.

Most of the protein in the diet should come from plant sources as it comes with complete numerous cancer fighting nutrients and phytochemicals.

Decreased risk was associated with high intakes of soya proteins, total soya products and a high proportion of soya to total protein (Lee et al, 1991) .

The proteins from fatty fish come packaged with omega-3 fatty acids necessary for body’s defense system. They should provide the second highest amount of proteins in the diet.

Skinless poultry should make the smallest contribution to the amino acid pool.

Protein & cancer

Omega-3-fatty acids protect the cell from cancer development.

The biological activity of both the Lipid mobilizing factor (LMF) and Protein Mobilizing Factor (PMF) was shown to be attenuated by eicosapentaenoic acid (EPA) (Tisdale,M.J., 1999).

MUFA have shown neutral effect. There are several contradictory studies in this regard. In case-control studies conducted in Spain and Greece,

women who used more olive oil had reduced risks of breast cancer possibly related to its high content of monounsaturated fat and antioxidants (Martin Moreno et al, 1994).

Lipids, fats & cancer

• High intake of PUFA have shown to increase the development of breast, uterus, prostate & colon cancer.

• Linoleic acid have shown to be a causative factor of cancer.

• Clinical studies show that this PUFA is able to stabilize the rate of weight loss and adipose tissue and muscle mass in cachectic patients with unresectable pancreatic cancer (Tisdale, 1999).

• Decreased risk was associated with high intakes of polyunsaturated fatty acids (PUFA) and a high PUFA to saturated fatty acid ratio (Lee et al, 1991).

• A diet having a low content of total fat, the polyunsaturated fatty acids are more tumorigenic than the saturated fatty acids (Jensen and Madsen, 1988).

Vitamins & minerals and cancerVitamins & minerals have shown to have a protective role in

cancer.

Epidemiological studies have shown that there is an inverse relationship between the risk of carcinogenesis and the amounts of vitamin A and provitamin A ingested. The relationship has been found strongest for cancer of the lungs (Jensen and Madsen, 1988).

A diet rich in vitamin C gives a lower risk of developing cancer of the stomach and oesophagus in particular (Bjelke,1978).

Vitamin-C can inhibit the formation of carcinogenic nitroso-compounds (Mirvish et al, 1972).

Intake of 800 IU/day of vitamin D may be associated with enhanced survival rates among breast cancer cases (Gardland et al,2006).

Supplementation with selenium or vitamin E is associated with a reduction of prostate cancer risk(Meyer et al, 2005).

Calcium intake up to 1200mg/day seems to have a protective influence.

Most cases of colon cancer may be prevented with regular intake of calcium in the range of 1,800 mg per day, in a dietary context that includes 800 IU per day (20 μg) of vitamin D3. In women, an intake of approximately 1,000 mg of calcium per 1,000 kcal of energy with 800 IU of vitamin D would be sufficient (Gardland et al,2006).

Antioxidants & cancerEpidemiological studies strongly

suggest that high intakes of food rich in B-carotene as well as Vit.B & C decrease risk of some cancers.

Vit.E help to stabilise most of the oils derived from plant.

The antioxidant Vit. E activity decreases from delta to alpha tocopherol.

It also inhibits the formation of nitrosamines especially at low pH.

Selenium, manganese, zinc, copper and iron

are components of the antioxidant enzymes.

Glutathione peroxidase (GSH-Px) is selenium

dependent.

Manganese superoxide dismutase, copper-zinc superoxide dismutase (SOD) and catalase are enzyme antioxidants.

Selenium (Se) is an essential dietary component and is regarded as a protective agent against cancer. Se has a potential to be used not only in cancer prevention but also in cancer treatment where in combination with other anticancer drugs or radiation, it can increase efficacy of cancer therapy (Brozmanova et al,2010).

Nutritional copper deficiency may impair antioxidant status by decreasing the activity of these enzymes.

Table: Beneficial effects of nutrient antioxidants

Antioxidant Beneficial effect

B-carotene Reduced risk of various cancers especially lung cancer and also stomach, cervix, oesophageal and throat cancer

Vitamin C Reduced risk of upper gastrointestinal tract, cervix cancer, cardiovascular disease.

Vitamin E Significant decrease in the risk of oral and pharyngeal cancer, cardiovascular disease

Selenium Reduced risk of oesophageal and stomach cancer.

SOURCE: Mathur Pulkit, 1997, Natural Antioxidants in Our Diet, Nutrition, 31,4.

Table: Optimal plasma levels of antioxidants

Levels 25-35% below the optimal predict atleast 2-fold high risk.

Antioxidant Plasma level (micromol/litre)

Vitamin C ≥50

Vitamin E ≥30

Vitamin A ≥22

B-carotene ≥0.4

α-plus B-carotene ≥0.4-0.5

Source: Joseph Maria M. Antioxidants and cancer.A manual of second regional workshop on planning diet for

health, Indian Dietetic Association, 1999.

Phytochemicals & cancer

1. TERPENES: Terpenes: Carotenoids are one subclass of terpenes

that are present in tomatoes, orange, spinach. Act as antioxidants and inhibit tumor growth.

Lycopene: Most effective antioxidant, two times powerful as B-carotenes.(Research show that it reduce the risk of prostate cancer).

Limonoids: Detoxify carcinogens by making them more water soluble for excretion from the body. Limitation: Chemopreventive agent.

2. PHENOLS: Phenols: Subclass flavonoids scavenge free radical

compounds.

Phenolic compounds: Caffeic and ferulic acids act by preventing the formation of carcinogens from precursor compounds.

Isoflavones: Genisteim, phytoestrogens (Soya) act as antioxidants, carcinogen blockers and tumor suppressor. May exert a protective effect against hormone related cancer.

Soya products may protect against breast cancer in younger women since these foods are rich in phyto-oestrogens (Lee et al, 1991)

The plant lignan and isoflavonoid glycosides are converted by intestinal bacteria to hormone-like compounds with weak estrogenic and antioxidative activity; they have now been shown to influence not only sex hormone metabolism and biological activity but also intracellular enzymes, protein synthesis, growth factor action, malignant cell proliferation, differentiation and angiogenesis, making them strong candidates for a role as natural cancer protective compounds. (Herman, 1995).

3. THIOLS: Sulphur containing phytonutrient. Upregulate enzymes involved in detoxification of carcinogens and other foreign compounds.

4. LIGNANS: Lignan: Phytoestrogens protective against hormone-sensitive

cancer. Phytic acid: Suppress oxidant damage. May also induce

detoxification enzymes, inhibition of nitrosamine formation, provision of substrate for the formation of antineoplastic agents dilution binding the carcinogens in the digestive tract, alteration of hormone metabolism and antioxidant effects.

Probiotic & Cancer• Carcinogenic agents (aflatoxin, food dyes, pesticides, nitrites) & cancer causing agents in non-food (tobacco,drugs) are bioactivated by enzyme system in gut.

• These bioactivation can lead to cancer.

• The probiotic support by inhibiting the over growth of toxic bacteria.

• By competing for attachment sites and nutrients these beneficial bacteria inhibit the proliferation of non-beneficial organism.

• Lactobacillus & bifidobacteria also produces organic acid that reduce intestinal pH and retard the growth of pathogenic bacteria.

DIETARY FIBRE & CANCER• Dilute bile acids or binds to it thereby preventing mutation or cell proliferation.

• Fermentation of fibre results in formation of SCFAs lowering intestinal pH. This inhibits conversion of primary bile acids to secondary bile acids which can promote mutation in intestine.

• Fermentation of fibre produces butyrate which is antineoplastic.

• Speeding the passage of faeces through the large intestine so that carcinogens are in contact with the intestinal wall for much shorter period.

• Bulk & water of the faeces may dilute the carcinogens to a non-toxic level.

• In populations with low average intake of dietary fibre, an approximate doubling of total fibre intake from foods could reduce the risk of colorectal cancer by 40%. (Bingham et al, 2003).

• Fiber has been hypothesized to reduce risk of colon cancer by diluting potential carcinogens and speeding their transit through the colon, binding carcinogenic substances, altering the colonic flora, reducing the pH, or serving as the substrate for the generation of short-chain fatty acids that are the preferred substrate for colonic epithelial cells. (Willett, 2000).

Nutritional care in cancer

• A cancer patient needs a high-calorie, high protein diet.

• Cancer causes a hypermetabolic state.• Studies have shown that once lean body mass is

significantly depleted, regardless of the cause death follows.

• Without adequate nutrients body is poorly equipped to maintain immune defenses, support organ function, absorb nutrients and mend damaged tissues.

• Energy: For an adult with good nutritional status about 2000kcal and for malnourished patient about 3000-4000kcal can be given or 45-50kcal/kg body weight may be recommended.

• Protein: For an adult with good nutritional status about 80-100g may be recommended or

1-1.2g/kg for those with good nutrition 1.3-2g/kg for malnourished patients

• Vitamins & Minerals: Optimal intake are recommended. There are mounting evidence that vitamins protect against several types of cancer.

• Fluid: Sufficient fluids need to be ingested.

Conclusion Abnormal cell growth.

Can occur in any body tissue. Treatment: Chemotherapy, radiation, surgery.

Parenteral or enteral nutrition may be necessary in the early stages of recovery.

Hypermetabolic state. Demand high energy & protein.

Antioxidants, phytochemicals & probiotics can be preventive.

Let food be your medicine and let medicine be your food.

REFERENCETEXT BOOKS:1. Keane,M and Chace,D. What to eat if you have cancer.

Updated Second Edition. 2007. McGraw Hills Publisher. New York.

2. Mudambi,S.R and Rajagopal,M.V. Fundamentals of Foods, Nutrition and Diet Therapy. Fifth Edition. 2007. New Age International Publishers. New Delhi.

3. Srilakshmi,B. Dietetics. Fifth Edition. 2005. New Age International Publishers. New Delhi.

4. Lodish,H., Berk,A and Zipursky,S.L. Molecular Cell Biology. 4th edition. 2000. W. H. Freeman. New York

JOURNAL• Austin,H., Austin,J.M., Partridge,E.E. 1991. Endometrial cancer, obesity, and

body fat distribution. Journal of Cancer Research. 51:568-572.

• Bingham, A.S. Day,N.E., Luben,R., Ferrari,P., Slimani,N., Norat,T., Clavel-Chapelon,F., Kesse,E., Nieters,A., Boeing,H., Tjϕnneland,A., Overvad,K., Martinez,C., Dorronsoro,M., Gonzalez,C.A., Key,T.J., Trichopoulou,A., Naska,A., Vineis,P., Tumino,R., Krogh,V., Bueno-de-Mesquita,H.B.,Peeters,P.H.M., Berglund,G,B., Hallmans,G., Lund,E., Skeie,G., Kaaks, and Riboli,E. 2003. Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. The Lancet. 361 (9368): 1496-1501.

• Bjelke,E. 1978. Dietary factors and the epidemiology of cancer of the stomach and large bowel. Aktuel Ernaehrungsmed Klin Prax (Suppl). 2: 1-7

• Brozmanova,J., Mániková,D., Vlčková,V., Chovanec,M. 2010. Selenium: a double-edged sword for defense and offence in cancer. Archives of Toxicology. 84(12): 919-938 .

• Cairns,R.A., Harris,I.S., Mak ,T.W. 2011. Regulation of cancer cell metabolism. Nat Rev Cancer. 11:85-95.

• Cangiano,C., Laviano,A., Muscaritoli,M., Meguid,M.M., Cascino,A., Fanelli,F.R. 1996. Cancer anorexia: new pathogenic andtherapeutic insights. Journal of Nutrition. 12(1): S48–S51

• Engeland,M.V., Weijenberg,M.P., Roemen,G.M.J.M., Brink,M., Bruïne,A.P., Goldbohm,R.A., Brandt,P.A.V.D., Baylin,S.B., Goeij,A.F.P.M and Herman,J.G. 2003. Effects of Dietary Folate and Alcohol Intake on Promoter Methylation in Sporadic Colorectal Cancer: The Netherlands Cohort Study on Diet and Cancer. Journal of Cancer Research. 63: 3133.

• Garland,C., Frank,C., and Gorham,E.D. 2006. Calcium And Vitamin D: Their Potential Roles In Colon And Breast Cancer Prevention, Annals Of The New York Academy Of Sciences. 889(1).

• Herman,c., Adlercrea,t., Goldin,b.R., Gorbach,s.L.,Ha–ckerstedt,K.A.V., Watanabe,s., Markkanen,M.H., Kristiina,T.W. 1995. Soybean Phytoestrogen Intake And Cancer Risk. Journal Of Nutrition. 125:757s-770s.

• International Agency for Research on Cancer. 1993: 599.

• Jensen,H and Madsen,J.L. 1988. Diet And Cancer. Acta Med Scand. 223: 293-304.

• Lee,H.P., Lee,J., Gourley,L., Duffy,S.W., Day,N.E and Estève,J. 1991. Dietary effects on breast-cancer risk in Singapore. The lancet. 337(8751): 1197–1200

• Martin-Moreno,JM., Willett,W.C., Gorgojo,L.1994. Dietary fat, olive oil intake and breast cancer risk. International Journal of Cancer. 58:774-780.

• Meyer,F., Galan,P., Douville,P., Bairati,I., Kegle,P., Bertrais,S., Estaquio,C and Hercberg,S.2005. Antioxidant vitamin and mineral supplementation and prostate cancer prevention in the SU.VI.MAX trial. International Journal of Cancer. 116(2) :182–186.

• Mirvish,S.S., Wallcave,L., Eagan,M., Shubik,P. 1972. Ascorbate-nitrite Reaction: Possible Means Of Blocking The Formation Of Carcinogenic N-nitroso Compounds. Journal Of Science.177: 65-8.

• Muthia,R., Wahyu,W., and Dachriyanus. 2013. Effect Of Ginger Infusion On Chemotherapy Induced Nausea And Vomiting In Breast Cancer Patients, Journal Of Biology Agriculture And Healthcare. 3(13).

• Sanchez,M. J., Martínez,C., Nieto,A., Castellsague,X., Quintana,M.J., Bosch,F.X., Munoz,N., Herrero,R and Franceschi,S. 2003. Oral and oropharyngeal cancer in Spain: influence of dietary patterns, European Journal of Cancer Prevention. 12(1): 49-56

• Tajima,K and Tominaga,S. 1985. Dietary habits and gastro-intestinal cancers: a comparative case-control study of stomach and large intestinal cancers in Nagoya, Japan. Japanese Journal of Cancer Research. 76(8):705-716.

• Tennant,d.A., Durán,r.V., Gottlieb,e. 2010. Targeting Metabolic Transformation For Cancer Therapy. National Rev Cancer. 10:267-277.

• Tisdale,M.J. 1999. Wasting in Cancer. Journal of Nutrition. 129(1): 243S-246S.

• Warburg,O. 1956. On the origin of cancer cells. Journal of Science. 123:309-314.

• Watson,l. 1963. Hypercalcaemia And Cancer. Postgrad. Med. Journal. 39(646).

• Willett,W.C. 2000. Diet and Cancer. The Oncologist. 5(5): 393-404.

*****

OCTOBER